June 23, 2018
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My bum knee: Part II

By Dr. Erik Steele

A few weeks ago, I let some people I don’t know very well put me to sleep, cut open my bum right knee, stick in some metal tools, and whack out some torn cartilage. I trusted them so completely to take good care of me that my heart rate just before sack out ‘n’ whack out time was lower than it would have been had Dunkin’ Donuts run out of coffee.

You might think I could be that relaxed because I had researched exactly what procedure offered me the best chance of a good result, which hospitals and surgeons had the lowest rate of infections and other complications doing this procedure, etc. You might think I — a high-muck-a- muck physician healthcare executive — could do some kind of real comparison of how likely surgeon A in hospital No. 1 would be to make my bum knee the best it could be, with the lowest risk of complications, compared to surgeon B in hospital No. 2.

You’d be wrong. I made my decision about who would do my surgery based on my family doctor’s recommendation, and my hospital choice based on what hospital I knew best. My family doc referred me to one particular surgeon because that surgeon took good care of other patients my doc had referred to him, had good training, did a lot of similar procedures and because he had a good reputation. I don’t think my family doc had any better real data to go on than I did when deciding who should do my surgery, data such as a large analysis of how that surgeon’s knee patients did over the long haul, sophisticated studies of his complication rates, etc.

What does it mean when two very influential physicians with access to all kinds of information about physicians and the quality of care they provide don’t have really good comparative information about which surgeons would provide the best care for them and their patients? Simple: it means that kind of information does not exist about most surgeons, surgical procedures, or hospitals where the surgery is performed. For most care we receive, we simply cannot reliably compare one hospital, or one surgeon, or one family doc, to another.

Even when we can get what looks like good information — comparisons of surgical infections for surgeons or hospitals doing the same procedure — we often have little idea how reliable that information really is. If the sample size was small, if Dr. Femur-Whacker with the higher infection rate had more diabetic patients than Dr. Art Rittic with the lower infection rate, the comparative numbers may be meaningless.

That means we are often stuck instead making assumptions based on surrogate measures of quality. We compare hospital size because there is some evidence that the more procedures a hospital and a surgeon do together, the better their outcomes. However, those studies compare classes of hospitals (larger versus smaller), and not one specific hospital to another. That makes it difficult to know if the results apply to a specific larger or smaller hospital to which you have access.

We use reputation as a surrogate, hoping that if a surgeon or hospital has a good reputation with our family doc, they must be pretty good. We use awards and “seals of approval,” from external expert healthcare agencies such as The Joint Commission. These also, however, do not reliably tell us about our individual chances of doing well after undergoing a specific procedure at the hands of a specific surgeon at such hospitals.

How do we make up for this lack of good, reliable information? Gather all the information we can, get second opinions before we have a procedure we might not need, search websites such as hospitalcompare .hhs.gov for what quality data does exist, ask why you are being referred to one particular surgeon or specialist versus another, ask surgeons how often they and their surgical team do this procedure, etc. Be a better part of the surgical team than most patients: be informed, ask good questions, make sure everyone who touches you cleans their hands in front of you, ask for good instructions and follow them carefully, etc.

At this point, that’s about all we’ve got.

Erik Steele, a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.


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